PMT16-02206 City of Menifee Permit No.: PMT16-02206
_ 29714 HAUN RD.
<-�CCEL/-> MENIFEE, CA 92586 Type: Residential Electrical
MENIFEE Date Issued: 07/1312016
PERMIT
Site Address: 27012 BOTTLEBRUSH LN, MENIFEE, CA Parcel Number: 335-363-027
92586 Construction Cost: $1,000.00
Existing Use: Proposed Use:
Description of ELECTRICAL PANEL UPGRADE TO 200AMPS FOR SOLAR PERMIT PMT16-01709
Work:
Owner Contractor
ANN YOUNG VISION INSTALLATION
27012 BOTTLEBRUSH LN 5255 N EDGEWOOD DR_125
MENIFEE, CA 92586 PROVO, UT84604
Applicant Phone:8887817074
KELLY BAKER License Number:853582
5255 N EDGEWOOD DR_125
PROVO,CA 84604
Fee Description gyt Amount IS7
Receptacle, Switch, Outlet&Fixture 1 116.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Electrical 1 5.80
$149.30
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carved on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee.Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance,or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Bldg_Permit Templale.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION ❑ I am exempt from licensure under the Contractors'State License Law for the
I hereby affirm under penalty or perjury that I am licensed under provisions of following reason:
Chapter 9(commencing with section 7000)of Division 3 of the Business and By my signature below I acknowledge that,except for my personal residence in
Professions Code and my license is in full force and eff ct which I must have resided for at least one year prior to completion of
License Class f C —)O License No. 35 Improvements covered by this permit. I cannot legally sell a structure that I have
Expires 1 //7 f�) 7 Signatur built as an owner-building if it has not been constructed in its entirety by licensed
contractors. I understand that a copy of the applicable law,Section 7044 of the
WORKERS'COMPENSATION DECLARATGN Business and Professions Code,is available upon request when this application is
submitted or at the fallowing Web site:
ereby affirm under penalty of perjury one of the following declarations: htto://www.leainfo.ca.gov/calaw.hlml.
I ave and will maintain a certificate of consent of self-insure for workers'
compensation,issued by the Director of Industrial Relations as provided for by Date
Section 3700 of the Labor Code, for the performance of work for which this
permit is issued. �� Property Owner orAuthorized Agent
�Policy# , ff�"'�/�� -`i'�'j ❑ By my Signature below, I certify to each of the following: I am the property
I have and will maintain workers compensation insurance, as required by owner or authorized to act on the property owner's behalf. I have read this
son 3700 of the Labor Code, for the performance of the work for which this application and the information I have provided is correct. I agree to comply
permit is issued.My workers'compensation insurance carer and policy numberare: with all applicable city and county ordinances and state laws relating to building
/ -I construction.I authorize representatives of this city or county to enter the above-
Carrier,!!2 �"G 12ZooI Identified propertyforl e' spectio puryoses.
Policy# �o�f�_ ).�Expires Date 1/,')
Prope Own Authorized Agent / 1,,
(This section need J1s be completed if the permit is for City Business License# 0���[6 YJ
one-hundred dollars($100)or less)
HAZARDOUS MATERIAL DECLARATION
ycertify that in the performance of the work for which this permit is issued,I
shall not emolov any persons in any manner so as to become subject to the Will the applicant or future building occupant handle hazardous material or a
workers'compensation laws of California,and agree that ff I should become mixture containing a hazardous material equal to or greater that the
subject to the workers'compensation provisions of Section 3700 of the Labor amounts pacified on the Hazardous Materials Information Guide?
Code,I shall orthwilh ply�w,rith those p/r`ovisions. ❑YESNO
Applies Will the intended use of the building by the applicant or future building
occupant require a permit for the construction or modification from South
WARNING: FAILURE TO SECURE WORKERS' Coast Air Quality Management District(SCAQMD)?See permitting checklist
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL for guidelin s
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND DYES Y
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS
($100,000), IN ADDITION TO THE COST OF COMPENSATION, Will the proposed building or modified facility be within 1000 feet of the outer
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE boundary of a school?
LABOR CODE, INTEREST,AND ATTORNEYS FEES ❑YES 1310
CONSTRUCTION LENDING AGENCY I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm that under the penalty of perjury there is a construction lending permitting checklist.I understand my requirements under the State of
agency for the performance of the work which this permit is issued (Section California Health&Safety Code,Section 25505 and 25534 concerning
3097 Civil Code) hazardous,material re orting.
OWNER BUILDER DECLARATIONS DYE r'01N„`,'
I hereby affirm under penalty of perjury that I am exempt from the Contractors Date! S
License Law for the reason(s)indicated below by the checkmark(s)I have placed OP RTY O ER OR AUTHORIZED AGENT
next to the applicable ilem(s)(Section 7031.5.Business and Professions Code:
Any city or county that requires a permit to construct, alter, improve, demolish, EPA RENOVATION,REPAIR AND PAINTING(RRP)
or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the The EPA Renovation,Repair and Painting(RRP)Rule requires contractors
provisions of the Contractor's Stale License Law(Chapter 9 (commencing with receiving compensation for most work that disturbs paint in a pre-1978
Section 7000)of Division 3 of the Business and Professions Code)or that he or residence or childcare facility to be RRP-certified firms and comply with
she is exempt from licensure and the basis for the alleged exemption. Any required practices.This includes rental property owners and property
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to managers who do the paint-disturbing work themselves or through their
a civil penalty of not more than($500).) employees.For more information about EPA's Renovation Program visit:
www.epa.00vliead or contact the National Lead Information Center at
❑ I, owner of the property, or my employees with wages s their sale 1.80DA24-LEAD(5323).
compensation, will do ( )all of or( )porting of the work, and thee structure is
not intended or offered for sale.(Section 7044,Business and Professions Code;
The Contractor's State License Law does not apply to an owner of a property ❑An EPA Lead-Safe Certified Renovator will be responsible for this project
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale.If,however, Certified Firm Name:
the building or improvement is sold within one year of completion, the Owner-
Builder will have the burden of proving that it was not built or improved for the Firm Certification No:
purpose of sale).
❑ 1, as owner of the property an exclusively contracting with licensed El No EPA Lead-Safe Certified Firm is required for this project because:
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractor's License Law does not apply to an owner of a property
who builds or improves thereon, and who contracts for the projects with a
licensed contractor(s)pursuant to the Contractors State License Law). If your project does not comply with EPA RRP rule please fill out the RRP